Basic Information
| Provider Information | |||||||||
| NPI: | 1215241153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | POOJA | ||||||||
| MiddleName: | SAROJ | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VAIDYA | ||||||||
| OtherFirstName: | POOJA | ||||||||
| OtherMiddleName: | UDAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 875 POPLAR CHURCH RD | ||||||||
| Address2: | STE 320 | ||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170112203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177637400 | ||||||||
| FaxNumber: | 7177634177 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 S CEDAR CREST BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104026555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2010 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 014136 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | MA055008 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.